[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[Localization of peripheral nerves. Success and safety with electrical nerve stimulation]. / Lokalisation peripherer Nerven. Erfolg und Sicherheit mit elektrischer Nervenstimulation.

Peripheral electrical nerve stimulation is one of the standard applications in peripheral regional anesthesia in addition to the ultrasound technique. Among other findings, the visualization of needle and nerve during ultrasound-guided blockade caused a change in clinical practice of peripheral nerve stimulation in the last decade. In the present article old and new aspects of principles and clinical practice of the nerve stimulation technique are presented and summarized in a total clinical concept in order to achieve safe and successful peripheral regional anesthesia using electrical peripheral nerve stimulation.

[Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]. / Management der postpartalen Blutung (PPH): Algorithmus der Interdisziplinären D-A-CH-Konsensusgruppe PPH (Deutschland - Österreich - Schweiz).

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

[Peripheral regional anesthesia in patients under general anesthesia: risk assessment with respect to parasthesia, injection pain and nerve damage]. / Periphere Regionalanästhesie beim Patienten in Allgemeinanästhesie : Risikobewertung bezüglich Parästhesie, Injektionsschmerz und Nervenschäden.

Nerve injury after peripheral regional anesthesia is rare and is not usually permanent. Some authors believe that inducing peripheral nerve blocks in patients during general anesthesia or analgosedation adds an additional risk factor for neuronal damage. This is based on published case reports showing that there is a positive correlation between paresthesia experienced during regional anesthesia and subsequent nerve injury. Therefore, many sources recommend that regional nerve blocks should only be performed in awake or lightly sedated patients, at least in adults. However, there is no scientific basis for this recommendation. Furthermore, there is no proof that regional anesthesia performed in patients under general anesthesia or deep sedation bears a greater risk than in awake or lightly sedated patients. Currently anesthesiologists are free to follow personal preferences in this matter as there is no good evidence favoring one approach over the other. The risk of systemic toxicity of local anesthetic agents is not higher in patients who receive regional anesthesia under general anesthesia or deep sedation. Finally, in children and uncooperative adults the administration of peripheral nerve blocks under general anesthesia or deep sedation is widely accepted.

Efficacy and safety of 10% HES 130/0.4 versus 10% HES 200/0.5 for plasma volume expansion in cardiac surgery patients.

AIM: Hydroxyethyl starch (HES) solutions are frequently used for perioperative volume replacement. Whereas older HES specimen tended to accumulate in the plasma and to cause negative effects on hemostasis, more recent products, e.g., HES 130/0.4, are characterised by improved pharmacological properties. The present study was designed to compare the efficacy and safety of 10% HES 130/0.4 and 10% HES 200/0.5. METHODS: In this post-hoc analysis of a prospective, randomised, double-blind, multi-center therapeutic equivalence trial, 76 patients undergoing elective on-pump cardiac surgery received perioperative volume replacement using either 10% HES 130/0.4 (N.=37) or 10% HES 200/0.5 (N.=39) up to a maximum dose of 20 mL kg-1. RESULTS: Equivalent volumes of investigational medication were infused until 24 hours after the first administration (1577 vs. 1540 mL; treatment difference 37 [-150; 223] mL; P<0.0001 for equivalence). Whereas standard laboratory tests of coagulation were comparable between groups, von Willebrand factor activity on the first postoperative morning tended to be higher following treatment with 10% HES 130/0.4 as compared to 10% HES 200/0.5 (P=0.025) with this difference being statistically significant only in the per-protocol analysis (P=0.02). Treatment groups were comparable concerning other safety parameters and the incidence of adverse drug reactions. In particular, renal function was well preserved in both groups. CONCLUSION: Ten percent HES 130/0.4 was equally effective and safe as compared to 10% HES 200/0.5 for volume therapy in patients undergoing cardiovascular surgery. Postoperative coagulation and renal function, as measured by standard laboratory tests, were similar among groups.

Transplacental transfer of remifentanil in the pregnant ewe.

BACKGROUND AND PURPOSE: While remifentanil can be used either during labour or fetal surgery, more should be known about the transplacental transfer of this opioid. The aim of this study was to investigate the placental transfer and haemodynamic effects of remifentanil after i.v. administration to pregnant ewes. EXPERIMENTAL APPROACH: Seven pregnant ewes received a continuous infusion of remifentanil (0.33 µg·kg⁻¹·min⁻¹) for 1 h, and maternal and fetal arterial blood samples were drawn at regular intervals during and up to 1 h after the discontinuation of the infusion. Haemodynamic parameters were monitored continuously. Blood gas samples were drawn at baseline and once during the infusion. KEY RESULTS: Peak maternal remifentanil plasma levels of 4.0 ± 0.9 ng·mL⁻¹ (mean ± SD) and peak fetal plasma levels of 0.4 ± 0.3 ng·mL⁻¹ were obtained. Remifentanil plasma levels dropped rapidly after the discontinuation of the infusion. The continuous infusion of remifentanil did not result in significant maternal or fetal haemodynamic changes. CONCLUSIONS AND IMPLICATIONS: Remifentanil rapidly passes through the placenta of pregnant ewes and although remifentanil concentrations stay significantly lower in the fetus compared with those in the mother, remifentanil can be detected in significant amounts in the fetus.

[Recommendations for the administration of conventional and new antithrombotic agents from the perspective of anesthesiology]. / Empfehlungen für die Anwendung konventioneller und neuer Antithrombotika aus anästhesiologischer Sicht.

Neuraxial blockade confers benefits to surgical patients not only due to the high analgesic quality but also through a reduction in postoperative complications, such as respiratory insufficiency and a shortening of postoperative paralytic ileus. In orthopedic surgery peripheral and neuraxial blockades are extensively used to enhance postoperative mobilization. The most serious complication of neuraxial blockade is spinal epidural hematoma, which may lead to permanent paraplegia if left untreated. The risk is enhanced in patients receiving thromboembolism prophylaxis. Most national societies have issued guidelines with specific time intervals between application of antithrombotic drugs and subsequent neuraxial blockade to minimize this risk. From the viewpoint of an anesthesiologist it is preferable to start with chemical thromboembolism prophylaxis postoperatively as opposed to preoperatively, to administer all drugs in the evening and to limit the number of available drugs at each site. The safety of neuraxial blockade in the presence of the new oral anticoagulant rivaroxaban is currently unknown due to limited experience and dabigatran is considered contraindicated with indwelling epidural catheters according to the manufacturer.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system.

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

[Oral prevention of thromboembolism with rivaroxaban and dabigatran: are the newly approved drugs innovations in orthopaedic and trauma surgery? ]. / Orale Thromboembolieprophylaxe mit Rivaroxaban und Dabigatran: Sind die Neuzulassungen Innovationen für die operative Orthopädie und Unfallchirurgie?

Today the indication for thrombosis prophylaxis is a relevant and daily concern in orthopaedic surgery. Recently there are some changes concerning the German guidelines, which are approved by 27 German medical societies. For the first time the guidelines give distinct recommendations for the different indications, the kind of thrombosis prophylaxis and its duration. Some of the recommendations will lead to changes of both processes in outpatient and inpatient management. In parallel 2 new oral anticoagulants have been approved for the prevention of thromboembolic events after elective knee and hip replacement. Dabigatran is an oral thrombin inhibitor. Compared to enoxaparin it has a comparable profile of side effects and efficacy. Rivaroxaban is an oral Xa inhibitor which shows a significantly better efficacy compared to enoxaparin and no difference in side effects. The significant reduction of symptomatic thromboembolisms after elective knee and hip replacement was shown for rivaroxaban compared to enoxaparin in a pooled analysis of phase III data. This review discusses the main topics of the new German guideline and impact of the new oral anticoagulants on in- and outpatient treatment procedures.

[Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]. / Die intensivmedizinische Versorgung herzchirurgischer Patienten: Hämodynamisches Monitoring und Herz-Kreislauf-Therapie S3-Leitlinie der Deutschen Gesellschaft für Thorax-, Herz- und Gefässchirurgie (DGTHG) und der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

[The use of antithrombotic drugs during various surgical procedures]. / Besonderheiten des Antithrombotikaeinsatzes bei verschiedenen chirurgischen Eingriffen.

Neuraxial blockade has been shown to provide essential benefits in terms of reduced perioperative morbidity and mortality. Case series from recent years indicate that spinal epidural hematoma is more common than previously estimated, with incidences of 1:200,000 in obstetric patients and as high as 1:3,600 in female orthopedic patients. To lower this risk, societies worldwide have issued guidelines establishing recommended time intervals between administration of antithrombotic drugs and performance of neuraxial blockade. If adherence to these intervals imposes a high risk of theomboembolic complications, neuraxial blockade should be withheld in favor of continued antithrombotic therapy. In such patients an alternative plan for postoperative pain management such as patient-controlled intravenous analgesia or peripheral nerve blocks should be established. In patients on continued acetylsalicylic acid therapy, neuraxial blockade may be performed if thromboembolism prophylaxis is not administered concurrently.

The excor device - revival of an old system with excellent results.

OBJECTIVE: We report on our experience with the BerlinHeart Excor system in adults and paediatric patients who underwent placement of the mechanical support device under emergency conditions and demonstrate the exceptional advantages and the considerable versatility of the system. METHODS: Since 2003, 29 consecutive patients (25 adults and 4 infants) with ages ranging from 10 months to 54 years underwent implantation of an Excor system. Main underlying heart diseases in adults were acute myocardial infarction (n = 9), dilative cardiomyopathy (n = 6), acute myocarditis (n = 6), whereas most of the children suffered from dilative cardiomyopathy. Ten patients had undergone implantation of an extracorporeal membrane oxygenation system. RESULTS: In 26 cases, a left ventricular assist device (LVAD) was implanted, while 3 patients had biventricular support. The support interval of all patients surviving the perioperative period lasted from 30 to 412 days, mean period of support until heart transplantation or explantation was 184 +/- 117 days. Severe complications were rare. CONCLUSION: The Excor paracorporeal mechanical support system is an excellent and highly versatile device for the support of patients of all ages and different types of underlying heart disease in the mid-term and long-term. The implant procedure and the perioperative management are simple, and complication rates are low.

[Current concepts in neuraxial anaesthesia for labour and delivery]. / Regionalanästhesie in der Geburtshilfe -- neue Entwicklungen.

Epidural analgesia for labour has been associated with an increased rate of motor blockade, and instrumental and Caesarean deliveries. In recent years, these risks were significantly reduced with modern concepts of epidural analgesia, including the use of lower doses of local anaesthetics in combination with opioids. With combinations of 0.0625-0.125 % of bupivacaine plus sufentanil or fentanyl, the incidence of maternal motor blockade approximates 10 % and most parturients are nowadays able to ambulate during labour. Methods of epidural drug administration consist of intermittent boluses, patient-controlled epidural analgesia (PCEA) or continuous infusions. While intermittent top-ups and PCEA do not differ in the amount of local anaesthetics used, continuous infusions have been associated with increases in drug consumption and motor blockade in addition to a higher workload (e. g. frequent adjustments of infusion rates). They therefore do not appear to confer significant benefits during labour analgesia. The most common type of anaesthesia for Caesarean delivery is spinal anaesthesia due to its simplicity, cost-effectiveness and speed of onset. It is suitable for cases of an urgent or emergent Caesarean delivery. General anaesthesia still leads to a higher maternal mortality and should be reserved for absolute emergencies and cases where neuraxial blockade is contraindicated.

Effects of cafedrine/theodrenaline, etilefrine and ephedrine on uterine blood flow during epidural-induced hypotension in pregnant sheep.

INTRODUCTION: Maternal hypotension is a major concern in obstetric anesthesia, and concerns have been raised about standard vasopressor therapy with ephedrine. Therefore, we evaluated the maternal and fetal hemodynamic effects of two potential alternatives to ephedrine. METHODS: Hypotension was induced by epidural administration of lidocaine in 6 chronically instrumented pregnant ewes (at 118-122 days of gestation, term 145 days). Three treatments were studied: 25 mg ephedrine, 5 mg etilefrine and 100 mg cafedrine/5 mg theodrenaline (C/T) intravenously. Mean fetal and maternal blood pressure and heart rate, uterine blood flow, as well as fetal and maternal arterial blood gases were recorded for 60 min. RESULTS: All three vasopressors increased maternal blood pressure, accompanied by a significant increase in uterine blood flow. C/T caused marked maternal tachycardia, whereas ephedrine decreased maternal heart rate. Maternal and fetal blood gases did not change during any of the three treatment regimens. CONCLUSION: All three vasopressors restored maternal blood pressure and uterine blood flow after epidurally induced maternal hypotension. However, restoration of uterine perfusion was delayed and less pronounced with C/T.

Assessment of volume preload on uteroplacental blood flow during epidural anaesthesia for Caesarean section.

BACKGROUND AND OBJECTIVE: Epidural and spinal anaesthesia are the preferred mode of anaesthesia for Caesarean section. Volume preloading is recommended to prevent maternal hypotension and a reduction in uteroplacental blood flow, although positive effects of volume preloading on maternal cardiac output and arterial pressure are debatable. Doppler measurements of the umbilical artery beyond deriving pulsatility indices are not routinely performed. METHODS: After Institutional Review Board approval and written informed consent, 14 consecutiVe women with epidural anaesthesia for Caesarean section received either hydroxyethyl starch 500 mL or gelatine 500 mL. Haemodynamic variables monitored were maternal arterial pressure, maximal blood flow velocity and pulsatility indices of the uterine artery derived from Doppler measurements. CONCLUSIONS: Maternal arterial pressure and pulsatility indices in both groups did not change from baseline after intravenous colloid infusion. However, uterine blood flow increased significantly in both groups. The effectiveness of volume preloading may therefore be better described by changes in maximum uterine blood flow velocity than by pulsatility indices or maternal arterial pressure.

[Venous thromboembolism prophylaxis]. / Venöse Thromboembolieprophylaxe.

Venous thromboembolism is a common and frequent complication of hospitalized patients. Some venous thromboembolisms may be subclinical, while others present as symptomatic deep vein thrombosis and/or pulmonary embolism. Venous thromboembolism and pulmonary embolism contribute significantly to inhospital morbidity and mortality. The risk of venous thromboembolism is aggravated by dispositional and/or expositional risk factors. In patients at intermediate or high risk of venous thromboembolism, additional pharmacological thromboembolism prophylaxis becomes mandatory.

A multicentre trial comparing different concentrations of ropivacaine plus sufentanil with bupivacaine plus sufentanil for patient-controlled epidural analgesia in labour.

BACKGROUND AND OBJECTIVE: To determine the optimal concentration of ropivacaine for bolus-only patient-controlled epidural labour analgesia, three different doses of ropivacaine were evaluated in comparison with bupivacaine in a double-blinded multicentre study. METHODS: Four hundred-and-fifty labouring parturients at term in three different academic institutions were randomized to four groups receiving bupivacaine 0.125% with sufentanil 0.75 microg mL(-1), ropivacaine 0.125% or 0.175% with sufentanil 0.75 microg mL(-1), or ropivacaine 0.2%. After an initial bolus of 10 mL of the study solution, and once visual analogue scores (VAS) were below 30 mm, patient-controlled epidural analgesia was initiated with a bolus of 4 mL, a lockout interval of 15 min and without a background infusion. Variables studied were the quality of analgesia, incidence of side-effects, the degree of motor blockade, and the mode of delivery. RESULTS: Bupivacaine 0.125% and ropivacaine 0.125% with sufentanil proved equally effective in providing labour analgesia without a difference in local anaesthetic consumption (48.6 +/- 23 mg bupivacaine vs. 52.1 +/- 38 mg ropivacaine), motor blockade or mode of delivery. Ropivacaine 0.175% plus sufentanil enhanced the quality of analgesia of the initial loading dose, whereas ropivacaine 0.2% without sufentanil increased the consumption of local anaesthetics (80.2 +/- 34 mg; P < 0.05) and the degree of motor blockade. CONCLUSION: Despite recent studies indicating that bupivacaine and ropivacaine may not be equipotent, both local anaesthetics provided equi-effective analgesia at equal doses without a difference in side-effects.

Stability of a sufentanil-ropivacaine mixture in a glass and a PVC reservoir.

BACKGROUND AND OBJECTIVE: Drug mixtures containing sufentanil may be unstable owing to absorption into the drug reservoirs of patient-controlled epidural analgesia systems that contain polyvinylchloride. The stability of sufentanil in a mixture of ropivacaine 0.2% in a 750 mL reservoir was therefore investigated. METHODS: During simulated epidural infusions of 5 mLh(-1) at 25 degrees C, sufentanil concentrations were measured for 96 h. Samples were taken from the reservoir and from the end of the epidural catheter under the following conditions: into glass or polyvinylchloride reservoirs containing ropivacaine 0.2% with sufentanil 1, 0.75 or 0.5 microg mL(-1); and into polyvinylchloride reservoirs with ropivacaine 0.2% and sufentanil 1 microg mL(-1) which were stored for 4 weeks at 8 degrees C. RESULTS: The different solutions remained stable over the observation period of 96 h. Using the same solutions, independent samples' ANOVA showed no difference in the sufentanil concentrations between the glass and polyvinylchloride reservoirs, or between the polyvinylchloride reservoirs when stored for 4 weeks. Correlations between the concentrations at the different measurement times were extremely high for the reservoir (r(min) = 0.98, r(max) = 1.00) and the catheter end (rmin = 0.86, r(max) = 1.00). CONCLUSIONS: Sufentanil citrate at 0.5-1.0 microg mL(-1) in an admixture of ropivacaine 0.29 for 5 days, which is the usual period for postoperative epidural analgesia, remains stable in a polyvinylchloride reservoir. There is no change in the drug concentration even if the reservoir is stored for 4 weeks at 8 degrees C.